Mental-health professionals fear overreaction in addressing violence

Originally published January 15, 2013 at 8:10 pm
Updated January 16, 2013 at 10:25 am

White roses with the faces of victims of the Sandy Hook Elementary School shooting are displayed Monday on a telephone pole near the school on the one-month anniversary of the mass shooting in Newtown, Conn.

No one but a deeply disturbed individual marches into an elementary school or a movie theater and guns down random, innocent people.

That hard fact drives the public longing for a mental-health system that produces clear warning signals and can somehow stop the violence. And it is now fueling a surge in legislative activity.,

But these proposed changes and others like them may backfire and only reveal how broken the system is, experts said.

“Anytime you have one of these tragic case like Newtown, it’s going to expose deficiencies in the mental-health system and provide some opportunity for reform,” said Richard Bonnie, a professor of public policy at the University of Virginia’s law school who led a state commission that overhauled policies after the 2007 Virginia Tech shootings that left 33 people dead. “But you have to be very careful not to overreact.”

New York state legislators Tuesday passed a gun bill that would require therapists to report to the authorities any client thought to be “likely to engage in” violent behavior; under the law, the police would confiscate any weapons the person had.

And in Washington, D.C., lawmakers said that President Obama was considering a range of actions as part of a plan to reduce gun violence, including more sharing of records between mental-health and law-enforcement agencies. The White House plan to make use of mental-health data was still taking shape late Tuesday.

But several ideas being discussed — including the reporting provision in the New York gun law — are deeply contentious and transcend political differences.

Some advocates favored the reporting provision as having the potential to prevent a massacre. Among them was D.J. Jaffe, founder of the Mental Illness Policy Org., which pushes for more-aggressive treatment policies.

Some mass killers “were seen by mental-health professionals who did not have to report their illness or that they were becoming dangerous and they went on to kill,” he said. Yet many patient advocates and therapists strongly disagreed, saying it would intrude into the doctor-patient relationship in a way that could dissuade troubled people from speaking their minds and complicate the many judgment calls therapists already have to make.

The New York statute requires doctors and other mental-health professionals to report any person who “is likely to engage in conduct that would result in serious harm to self or others.”

Under current ethical guidelines, only involuntary hospitalizations (and direct threats made by patients) are reported to the authorities. These reports then appear on a federal background-check database. The new laws would go further.

“The way I read the new law, it means I have to report voluntary as well as involuntary hospitalizations, as well as many people being treated for suicidal thinking, for instance, as outpatients,” said Paul Appelbaum, director of the Division of Law, Ethics and Psychiatry at Columbia University’s medical school. “That is a much larger group of people than before, and most of whom will never be a serious threat to anyone.”

One fundamental problem with looking for “warning signs” is that it’s more art than science. People with serious mental disorders, while more likely to commit aggressive acts than the average person, account for only about 4 percent of violent crimes overall.

The rate is higher when it comes to rampage or serial killings, closer to 20 percent, according to Michael Stone, a New York forensic psychiatrist who has a database of about 200 mass and serial killers.

He has concluded from the records that about 40 were likely to have had paranoid schizophrenia or severe depression or were psychopathic, meaning they were impulsive and remorseless.

“But most mass murders are done by working-class men who’ve been jilted, fired or otherwise humiliated — and who then undergo a crisis of rage and get out one of the 300 million guns in our country and do their thing,” Stone said.

The sort of young, troubled males who seem to psychiatrists most likely to commit school shootings — identified because they have made credible threats — often don’t qualify for any diagnosis, experts said. They might have elements of paranoia, of deep resentment or of narcissism, a grandiose self-regard, that are noticeable but do not add up to any specific “disorder” according to strict criteria.

“The really scary ones, you have a gut feeling right away when you talk to them,” said Deborah Weisbrot, director of the outpatient clinic of child and adolescent psychiatry at Stony Brook University in New York state, who has interviewed about 200 young people, mostly teenage boys, who have made threats. “What they have in common is a kind of magical thinking, odd beliefs like they can read other people’s minds, or see the future or that things happening in their dreams come true.”

Even if such instincts could be relied on, the mental-health system is so fragmented in this country that it’s hard to know whether the information would get to the right person in time. According to Bonnie, the Virginia law professor, the Virginia Tech gunman was ordered to outpatient treatment by a judge more than a year before his rampage, but was never hospitalized, which would have shown up on a background check. The state database now includes such cases, after the reforms.

“But we’re a state that has a centralized database like that; in many states there’s no one place to get it all; it’s all kept locally, community by community,” Bonnie said.

The federal background-check database, which is supposed to have updated information from states, has only a patchwork, because of the wide variety of state laws on reporting, experts said. Even if it were entirely up to date, it would not catch the many millions who never see a mental-health professional despite deep distress.

Some experts, like Appelbaum, say the Connecticut school tragedy offers the kind of opportunity that only comes once every generation or two: to rethink the entire mental-health system. It might include appointing a presidential commission; re-envisioning community mental-health care; focusing more on vigilance for problems in young people, and reducing stigma.

“It seems to me an opportunity to step back and rethink what the entire system should look like,” Appelbaum said.